Edward I. Lee

Abdominal wall repair using human acellular dermal matrix: a follow-up study

BACKGROUND The role of acellular dermal matrix (ADM) in abdominal wall reconstruction (AWR) is unclear. The aim of this study was to review the management, complications, and long-term outcomes of AWR using ADM in a large surgical cohort. METHODS Retrospective chart review of patients undergoing AWR using ADM from 2004 to 2007 was performed. Demographic data, comorbidities, complications, and long-term outcomes were collected. RESULTS There were 77 cases in 68 patients with mean age of 61.1 +/- 1.4 years. The most common indication was infected fascia (n = 19 [25%]). Wound closure was achieved in 75% of the cases via primary (n = 26 [45%]), secondary intention (n = 17 [29%]), or skin graft (n = 15 [26%]). Nonprimary closure was achieved in 5.7 +/- .7 months. There were 32 perioperative (39%) and 33 long-term (43%) complications. Over a mean follow-up period of 13.2 +/- 1.5 months, the hernia recurrence rate was 27% (n = 21). CONCLUSION Although ADM is a viable option in AWR, the high hernia recurrence rate warrants a continued search for alternative biologic materials to improve outcomes.

Nasal trauma and the deviated nose.

Summary: As the most prominent facial feature, the nose carries an increased risk of traumatic injury. Nasal fracture is the most common bone injury of the adult face and frequently results from motor vehicle accidents, sports-related injuries, and altercations. Although often initially considered minor, nasal fracture may eventually result in significant cosmetic or functional defects. Optimal management of nasal trauma in the acute setting is critical in minimizing secondary nasal deformities. In recent years, numerous guidelines have been described to refine and optimize acute nasal trauma management. However, restoration of pretraumatic form and function remains a challenge. Commonly the product of a poorly addressed underlying structural injury, posttraumatic nasal deformity requiring subsequent rhinoplasty or septorhinoplasty remains in as many as 50 percent of cases. In this article, the authors review the anatomic, diagnostic, and management considerations as well as discuss their own experience in approaching nasal trauma and the deviated nose.

Breast implant infections: Is cefazolin enough?

Background: Bacterial infection is a well-known risk of breast implant surgery, occurring in 2.0 to 2.5 percent of cosmetic cases and up to 20 percent of reconstructive cases. The Centers for Disease Control and Prevention recommends a first-generation cephalosporin for perioperative prophylaxis; however, no guidelines exist for the empiric treatment of established breast implant infections. A recent increase in methicillin-resistant Staphylococcus aureus infections has prompted interest in using alternative antibiotics with anti–methicillin-resistant S. aureus activity for both prophylactic and empiric therapy. The goal of the present study was to assess the bacteriology and antibiotic susceptibility of breast implant-related infections at two tertiary care hospitals in the Texas Medical Center to determine whether a baseline for empiric therapy for breast implant infections could be established. Methods: A retrospective review of patients who developed periprosthetic infections within 1 month after breast implant placement between 2001 and 2006 was completed. One hundred six patients with 116 infected breasts were identified. Patients were included in the study only if they had documented culture data. Results: Thirty-one breasts in 26 patients met inclusion criteria. Sixty-seven percent of the infected breasts had S. aureus infections; of these, 68 percent were methicillin-resistant S. aureus infections and 32 percent were methicillin-susceptible S. aureus infections. We noted Gram-negative rods and sterile cultures in 6 percent and 26 percent of breasts, respectively. Conclusions: Because of the high incidence of methicillin-resistant S. aureus infections in breast implant recipients, we believe that choosing an antibiotic with anti–methicillin-resistant S. aureus activity is justified for empiric treatment of breast implant infections, until culture and sensitivity data, if obtained, become available.

Changes in corneal topography with upper eyelid gold weight implants.

Purpose: To determine the effect of upper eyelid gold weight implantation on corneal astigmatism. Methods: This is a prospective, cohort study. Eighteen eyes of 18 patients underwent upper eyelid gold weight implantation for facial nerve palsy. Nine of these patients recovered facial nerve function and underwent elective removal of the gold weight. Corneal topography was performed before and after gold weight implantation. Corneal topography was also performed after gold weight removal in patients who recovered from facial nerve paralysis. Results: With-the-rule corneal astigmatism increased significantly by 1.4 diopters (D) ±2.0, from a mean of 0.3 to 1.7 D after gold weight implantation (p = 0.034). With-the-rule corneal astigmatism in patients who had gold weight removal decreased by 1.2 ± 2.1 D, from 2.2 to 1.0 D after gold weight removal (p = 0.136). Conclusions: Upper eyelid gold weight implantation causes an increase in corneal astigmatism, predominantly in the vertical axis, which appears to be reversible on removal of the gold weight.

Optimizing the Surgical Management of Zygomaticomaxillary Complex Fractures

Zygomaticomaxillary complex (ZMC) fractures are a group of fractures that can significantly alter the structure, function, and appearance of the midface, including the globe. Like other facial fractures, the optimal management of operative ZMC fractures requires anatomic reduction of all fractures followed by rigid internal fixation. However, surgical treatment of these fractures can be quite challenging with the potential for high rates of complications. The goal of this article is to provide an overview of ZMC fractures and discuss treatment options, with an emphasis on providing surgical pearls to optimize outcomes.

Vascular malformations: a review.

Identification and treatment of vascular malformations is a challenging endeavor for physicians, especially given the great concern and anxiety created for patients and their families. The goal of this article is to provide a review of vascular malformations, organized by subtype, including capillary, venous, lymphatic and arteriovenous malformations. Only by developing a clear understanding of the clinical aspects, diagnostic tools, imaging modalities, and options for intervention will appropriate care be provided and results maximized.

Aesthetic Alteration of the Chin

Genioplasty, the alteration of the chin through either osseous manipulation or implant augmentation, is an integral component of aesthetic surgery of the face. When performed with proper preoperative assessment and technical execution, the results can harmonize and restore balance between skeletal, soft tissue, and dental components of the lower face. To this end, proper understanding of the underlying anatomy and the changes associated with movement of the chin, alone or in conjunction with formal orthognathic surgery, is paramount. The author presents pertinent points on proper assessment, treatment planning, and a description of the surgical technique, and discusses complications and outcomes to optimize outcome.

Noninvasive Facial Rejuvenation. Part 3: Physician-Directed—Lasers, Chemical Peels, and Other Noninvasive Modalities

A proper knowledge of noninvasive facial rejuvenation is integral to the practice of a cosmetic surgeon. Noninvasive facial rejuvenation can be divided into patient- versus physician-directed modalities. Patient-directed facial rejuvenation combines the use of facial products such as sunscreen, moisturizers, retinoids, α-hydroxy acids, and various antioxidants to both maintain youthful skin and rejuvenate damaged skin. Physicians may recommend and often prescribe certain products, but patients are in control with this type of facial rejuvenation. On the other hand, physician-directed facial rejuvenation entails modalities that require direct physician involvement, such as neuromodulators, filler injections, laser resurfacing, microdermabrasion, and chemical peels. With the successful integration of each of these modalities, a complete facial regimen can be established and patient satisfaction can be maximized. This article is the last in a three-part series describing noninvasive facial rejuvenation. Here the authors review the mechanism, indications, and possible complications of lasers, chemical peels, and other commonly used noninvasive modalities.

Mild Ptosis Correction with the Stitch Method During Incisional Double Fold Formation

Background Numerous methods exist for simultaneous correction of mild blepharoptosis during double eyelid surgery. These methods are generally categorized into either incisional (open) or non-incisional (suture) methods. The incisional method is commonly used for the creation of the double eyelid crease in patients with excessive or thick skin. However, concurrent open ptosis correction is often marred by the lengthy period of intraoperative adjustment, causing more swelling, a longer recovery time, and an increased risk of postoperative complications. Methods The authors have devised a new, minimally invasive technique to alleviate mild ptosis during incisional double eyelid surgery. The anterior lamella is approached through the incisional technique for the creation of a double eyelid while the posterior lamella, including Mullers and levator muscles, is approached with the suture method for Mullers plication and ptosis correction. Results The procedure described was utilized in 28 patients from June 2012 to August 2012. Postoperative asymmetry was noted in one patient who had severe preoperative conjunctival scarring. Otherwise, ptosis was corrected as planned in the rest of the cases and all of the patients were satisfied with their postoperative appearance and experienced no complications. Conclusions Our hybrid technique combines the benefits of both the incisional and suture methods, allowing for a predictable and easily reproducible correction of blepharoptosis with an aesthetically pleasing double eyelid.

Frontal sinus fractures: a conservative shift.

This article reflects on the changing management of frontal sinus fractures. Severity of these injuries has decreased tremendously since the universal adoption of seat belts and air bags. Recently, there has been a shift from aggressive surgical management to more conservative management strategies, some forgoing surgery all together. New technologies, such as bioabsorbable plates and endoscopic sinus surgery, are leading the way in improved surgical management strategies and offer promising alternatives to the more traditional approaches.